Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

COMPR STEM 9MM MINI

Facility

$19,476.65

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,531.96
Max. Negotiated Rate	$18,697.58
Rate for Payer: Aetna Commercial	$14,997.02
Rate for Payer: Anthem Medicaid	$6,698.02
Rate for Payer: Anthem POS/PPO/Traditional	$15,191.79
Rate for Payer: Cash Price	$9,738.33
Rate for Payer: Cigna Commercial	$16,165.62
Rate for Payer: First Health Commercial	$18,502.82
Rate for Payer: Humana Commercial	$16,555.15
Rate for Payer: Humana KY Medicaid	$6,698.02
Rate for Payer: Kentucky WC Medicaid	$6,766.19
Rate for Payer: Medical Mutual Of Ohio HMO	$15,970.85
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$14,373.77
Rate for Payer: Molina Healthcare Benefit Exchange	$5,843.00
Rate for Payer: Molina Healthcare Medicaid	$6,832.41
Rate for Payer: Ohio Health Choice Commercial	$17,139.45
Rate for Payer: Ohio Health Group HMO	$14,607.49
Rate for Payer: Ohio Health Group PPO Differential	$3,895.33
Rate for Payer: Ohio Health Group PPO No Differential	$2,531.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,037.76
Rate for Payer: PHCS Commercial	$18,697.58
Rate for Payer: United Healthcare All Payer	$17,139.45

COMPR STEM 9MM MINI

Facility

$19,476.65

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,531.96
Max. Negotiated Rate	$18,697.58
Rate for Payer: Aetna Commercial	$14,997.02
Rate for Payer: Anthem POS/PPO/Traditional	$15,191.79
Rate for Payer: Cash Price	$9,738.33
Rate for Payer: Cigna Commercial	$16,165.62
Rate for Payer: First Health Commercial	$18,502.82
Rate for Payer: Humana Commercial	$16,555.15
Rate for Payer: Medical Mutual Of Ohio HMO	$15,970.85
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$14,373.77
Rate for Payer: Molina Healthcare Benefit Exchange	$5,843.00
Rate for Payer: Ohio Health Choice Commercial	$17,139.45
Rate for Payer: Ohio Health Group HMO	$14,607.49
Rate for Payer: Ohio Health Group PPO Differential	$3,895.33
Rate for Payer: Ohio Health Group PPO No Differential	$2,531.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,037.76
Rate for Payer: PHCS Commercial	$18,697.58
Rate for Payer: United Healthcare All Payer	$17,139.45

COMPR STEM 9MM STD

Facility

$16,926.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.38
Max. Negotiated Rate	$16,248.96
Rate for Payer: Aetna Commercial	$13,033.02
Rate for Payer: Anthem POS/PPO/Traditional	$13,202.28
Rate for Payer: Cash Price	$8,463.00
Rate for Payer: Cigna Commercial	$14,048.58
Rate for Payer: First Health Commercial	$16,079.70
Rate for Payer: Humana Commercial	$14,387.10
Rate for Payer: Medical Mutual Of Ohio HMO	$13,879.32
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$12,491.39
Rate for Payer: Molina Healthcare Benefit Exchange	$5,077.80
Rate for Payer: Ohio Health Choice Commercial	$14,894.88
Rate for Payer: Ohio Health Group HMO	$12,694.50
Rate for Payer: Ohio Health Group PPO Differential	$3,385.20
Rate for Payer: Ohio Health Group PPO No Differential	$2,200.38
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,247.06
Rate for Payer: PHCS Commercial	$16,248.96
Rate for Payer: United Healthcare All Payer	$14,894.88

COMPR STEM 9MM STD

Facility

$16,926.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.38
Max. Negotiated Rate	$16,248.96
Rate for Payer: Aetna Commercial	$13,033.02
Rate for Payer: Anthem Medicaid	$5,820.85
Rate for Payer: Anthem POS/PPO/Traditional	$13,202.28
Rate for Payer: Cash Price	$8,463.00
Rate for Payer: Cigna Commercial	$14,048.58
Rate for Payer: First Health Commercial	$16,079.70
Rate for Payer: Humana Commercial	$14,387.10
Rate for Payer: Humana KY Medicaid	$5,820.85
Rate for Payer: Kentucky WC Medicaid	$5,880.09
Rate for Payer: Medical Mutual Of Ohio HMO	$13,879.32
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$12,491.39
Rate for Payer: Molina Healthcare Benefit Exchange	$5,077.80
Rate for Payer: Molina Healthcare Medicaid	$5,937.64
Rate for Payer: Ohio Health Choice Commercial	$14,894.88
Rate for Payer: Ohio Health Group HMO	$12,694.50
Rate for Payer: Ohio Health Group PPO Differential	$3,385.20
Rate for Payer: Ohio Health Group PPO No Differential	$2,200.38
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,247.06
Rate for Payer: PHCS Commercial	$16,248.96
Rate for Payer: United Healthcare All Payer	$14,894.88

COMPUTER-ASSIST SURG NAV PROC

Facility

$9,100.84

Service Code	HCPCS 20985
Hospital Charge Code	76100360
Hospital Revenue Code	761
Min. Negotiated Rate	$1,183.11
Max. Negotiated Rate	$8,736.81
Rate for Payer: Aetna Commercial	$7,007.65
Rate for Payer: Anthem POS/PPO/Traditional	$7,098.66
Rate for Payer: Cash Price	$4,550.42
Rate for Payer: Cigna Commercial	$7,553.70
Rate for Payer: First Health Commercial	$8,645.80
Rate for Payer: Humana Commercial	$7,735.71
Rate for Payer: Medical Mutual Of Ohio HMO	$7,462.69
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,716.42
Rate for Payer: Molina Healthcare Benefit Exchange	$2,730.25
Rate for Payer: Ohio Health Choice Commercial	$8,008.74
Rate for Payer: Ohio Health Group HMO	$6,825.63
Rate for Payer: Ohio Health Group PPO Differential	$1,820.17
Rate for Payer: Ohio Health Group PPO No Differential	$1,183.11
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,821.26
Rate for Payer: PHCS Commercial	$8,736.81
Rate for Payer: United Healthcare All Payer	$8,008.74

COMPUTER-ASSIST SURG NAV PROC

Facility

$9,100.84

Service Code	HCPCS 20985
Hospital Charge Code	76100360
Hospital Revenue Code	761
Min. Negotiated Rate	$1,183.11
Max. Negotiated Rate	$8,736.81
Rate for Payer: Aetna Commercial	$7,007.65
Rate for Payer: Anthem Medicaid	$3,129.78
Rate for Payer: Anthem POS/PPO/Traditional	$7,098.66
Rate for Payer: Cash Price	$4,550.42
Rate for Payer: Cigna Commercial	$7,553.70
Rate for Payer: First Health Commercial	$8,645.80
Rate for Payer: Humana Commercial	$7,735.71
Rate for Payer: Humana KY Medicaid	$3,129.78
Rate for Payer: Kentucky WC Medicaid	$3,161.63
Rate for Payer: Medical Mutual Of Ohio HMO	$7,462.69
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,716.42
Rate for Payer: Molina Healthcare Benefit Exchange	$2,730.25
Rate for Payer: Molina Healthcare Medicaid	$3,192.57
Rate for Payer: Ohio Health Choice Commercial	$8,008.74
Rate for Payer: Ohio Health Group HMO	$6,825.63
Rate for Payer: Ohio Health Group PPO Differential	$1,820.17
Rate for Payer: Ohio Health Group PPO No Differential	$1,183.11
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,821.26
Rate for Payer: PHCS Commercial	$8,736.81
Rate for Payer: United Healthcare All Payer	$8,008.74

COMPUTER-ASSIST SURG NAV PROC

Professional

Both

$9,100.84

Service Code	HCPCS 20985
Hospital Charge Code	76100360
Hospital Revenue Code	761
Min. Negotiated Rate	$117.79
Max. Negotiated Rate	$9,100.84
Rate for Payer: Aetna Commercial	$235.21
Rate for Payer: Anthem Medicaid	$117.79
Rate for Payer: Buckeye Medicare Advantage	$9,100.84
Rate for Payer: Cash Price	$4,550.42
Rate for Payer: Cash Price	$4,550.42
Rate for Payer: Cigna Commercial	$239.29
Rate for Payer: Healthspan PPO	$213.05
Rate for Payer: Humana Medicaid	$117.79
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$188.18
Rate for Payer: Molina Healthcare CHIP/Medicaid	$120.15
Rate for Payer: Molina Healthcare Passport	$117.79
Rate for Payer: Multiplan PHCS	$5,460.50
Rate for Payer: Ohio Health Choice Preferred Health Choice	$6,370.59
Rate for Payer: UHCCP Medicaid	$3,185.29
Rate for Payer: Wellcare CHIP/Medicaid	$118.97

COMPUTER-ASSIST SURG NAV PRO(P

Professional

Both

$350.00

Service Code	HCPCS 20985
Hospital Charge Code	761P0360
Hospital Revenue Code	761
Min. Negotiated Rate	$117.79
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial	$235.21
Rate for Payer: Anthem Medicaid	$117.79
Rate for Payer: Buckeye Medicare Advantage	$350.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cigna Commercial	$239.29
Rate for Payer: Healthspan PPO	$213.05
Rate for Payer: Humana Medicaid	$117.79
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$188.18
Rate for Payer: Molina Healthcare CHIP/Medicaid	$120.15
Rate for Payer: Molina Healthcare Passport	$117.79
Rate for Payer: Multiplan PHCS	$210.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$245.00
Rate for Payer: UHCCP Medicaid	$122.50
Rate for Payer: Wellcare CHIP/Medicaid	$118.97

COMPUTER-ASSIST SURG NAV PRO(T

Facility

$8,750.84

Service Code	HCPCS 20985
Hospital Charge Code	761T0360
Hospital Revenue Code	761
Min. Negotiated Rate	$1,137.61
Max. Negotiated Rate	$8,400.81
Rate for Payer: Aetna Commercial	$6,738.15
Rate for Payer: Anthem Medicaid	$3,009.41
Rate for Payer: Anthem POS/PPO/Traditional	$6,825.66
Rate for Payer: Cash Price	$4,375.42
Rate for Payer: Cigna Commercial	$7,263.20
Rate for Payer: First Health Commercial	$8,313.30
Rate for Payer: Humana Commercial	$7,438.21
Rate for Payer: Humana KY Medicaid	$3,009.41
Rate for Payer: Kentucky WC Medicaid	$3,040.04
Rate for Payer: Medical Mutual Of Ohio HMO	$7,175.69
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,458.12
Rate for Payer: Molina Healthcare Benefit Exchange	$2,625.25
Rate for Payer: Molina Healthcare Medicaid	$3,069.79
Rate for Payer: Ohio Health Choice Commercial	$7,700.74
Rate for Payer: Ohio Health Group HMO	$6,563.13
Rate for Payer: Ohio Health Group PPO Differential	$1,750.17
Rate for Payer: Ohio Health Group PPO No Differential	$1,137.61
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,712.76
Rate for Payer: PHCS Commercial	$8,400.81
Rate for Payer: United Healthcare All Payer	$7,700.74

COMPUTER-ASSIST SURG NAV PRO(T

Facility

$8,750.84

Service Code	HCPCS 20985
Hospital Charge Code	761T0360
Hospital Revenue Code	761
Min. Negotiated Rate	$1,137.61
Max. Negotiated Rate	$8,400.81
Rate for Payer: Aetna Commercial	$6,738.15
Rate for Payer: Anthem POS/PPO/Traditional	$6,825.66
Rate for Payer: Cash Price	$4,375.42
Rate for Payer: Cigna Commercial	$7,263.20
Rate for Payer: First Health Commercial	$8,313.30
Rate for Payer: Humana Commercial	$7,438.21
Rate for Payer: Medical Mutual Of Ohio HMO	$7,175.69
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,458.12
Rate for Payer: Molina Healthcare Benefit Exchange	$2,625.25
Rate for Payer: Ohio Health Choice Commercial	$7,700.74
Rate for Payer: Ohio Health Group HMO	$6,563.13
Rate for Payer: Ohio Health Group PPO Differential	$1,750.17
Rate for Payer: Ohio Health Group PPO No Differential	$1,137.61
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,712.76
Rate for Payer: PHCS Commercial	$8,400.81
Rate for Payer: United Healthcare All Payer	$7,700.74

COMTAN(ENTACAPONE)200 MG TAB

Facility

$4.82

Service Code	NDC 65862065401
Hospital Charge Code	25000454
Hospital Revenue Code	637
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$4.63
Rate for Payer: Aetna Commercial	$3.71
Rate for Payer: Anthem POS/PPO/Traditional	$3.76
Rate for Payer: Cash Price	$2.41
Rate for Payer: Cigna Commercial	$4.00
Rate for Payer: First Health Commercial	$4.58
Rate for Payer: Humana Commercial	$4.10
Rate for Payer: Medical Mutual Of Ohio HMO	$3.95
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3.56
Rate for Payer: Molina Healthcare Benefit Exchange	$1.45
Rate for Payer: Ohio Health Choice Commercial	$4.24
Rate for Payer: Ohio Health Group HMO	$3.62
Rate for Payer: Ohio Health Group PPO Differential	$0.96
Rate for Payer: Ohio Health Group PPO No Differential	$0.63
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1.49
Rate for Payer: PHCS Commercial	$4.63
Rate for Payer: United Healthcare All Payer	$4.24

COMTAN(ENTACAPONE)200 MG TAB

Facility

$4.82

Service Code	NDC 65862065401
Hospital Charge Code	25000454
Hospital Revenue Code	637
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$4.63
Rate for Payer: Aetna Commercial	$3.71
Rate for Payer: Anthem Medicaid	$1.66
Rate for Payer: Anthem POS/PPO/Traditional	$3.76
Rate for Payer: Cash Price	$2.41
Rate for Payer: Cigna Commercial	$4.00
Rate for Payer: First Health Commercial	$4.58
Rate for Payer: Humana Commercial	$4.10
Rate for Payer: Humana KY Medicaid	$1.66
Rate for Payer: Kentucky WC Medicaid	$1.67
Rate for Payer: Medical Mutual Of Ohio HMO	$3.95
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3.56
Rate for Payer: Molina Healthcare Benefit Exchange	$1.45
Rate for Payer: Molina Healthcare Medicaid	$1.69
Rate for Payer: Ohio Health Choice Commercial	$4.24
Rate for Payer: Ohio Health Group HMO	$3.62
Rate for Payer: Ohio Health Group PPO Differential	$0.96
Rate for Payer: Ohio Health Group PPO No Differential	$0.63
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1.49
Rate for Payer: PHCS Commercial	$4.63
Rate for Payer: United Healthcare All Payer	$4.24

CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES

Facility

$125,997.87

Service Code	MSDRG 212
Min. Negotiated Rate	$85,498.56
Max. Negotiated Rate	$125,997.87
Rate for Payer: Anthem Medicaid	$85,498.56
Rate for Payer: Anthem Medicare Advantage/PPO	$89,998.48
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$125,997.87
Rate for Payer: CareSource Just4Me Medicare	$121,497.95
Rate for Payer: Humana KY Medicaid	$85,498.56
Rate for Payer: Humana Medicare Advantage	$89,998.48
Rate for Payer: Kentucky WC Medicaid	$86,353.54
Rate for Payer: Molina Healthcare Benefit Exchange	$107,998.18
Rate for Payer: Molina Healthcare Medicaid	$87,208.53

CONCUSSION WITH CC

Facility

$13,451.76

Service Code	MSDRG 089
Min. Negotiated Rate	$9,127.98
Max. Negotiated Rate	$13,451.76
Rate for Payer: Anthem Medicaid	$9,127.98
Rate for Payer: Anthem Medicare Advantage/PPO	$9,608.40
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,451.76
Rate for Payer: CareSource Just4Me Medicare	$12,971.34
Rate for Payer: Humana KY Medicaid	$9,127.98
Rate for Payer: Humana Medicare Advantage	$9,608.40
Rate for Payer: Kentucky WC Medicaid	$9,219.26
Rate for Payer: Molina Healthcare Benefit Exchange	$11,530.08
Rate for Payer: Molina Healthcare Medicaid	$9,310.54

CONCUSSION WITH MCC

Facility

$17,942.71

Service Code	MSDRG 088
Min. Negotiated Rate	$12,175.41
Max. Negotiated Rate	$17,942.71
Rate for Payer: Anthem Medicaid	$12,175.41
Rate for Payer: Anthem Medicare Advantage/PPO	$12,816.22
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$17,942.71
Rate for Payer: CareSource Just4Me Medicare	$17,301.90
Rate for Payer: Humana KY Medicaid	$12,175.41
Rate for Payer: Humana Medicare Advantage	$12,816.22
Rate for Payer: Kentucky WC Medicaid	$12,297.16
Rate for Payer: Molina Healthcare Benefit Exchange	$15,379.46
Rate for Payer: Molina Healthcare Medicaid	$12,418.92

CONCUSSION WITHOUT CC/MCC

Facility

$10,935.47

Service Code	MSDRG 090
Min. Negotiated Rate	$7,420.50
Max. Negotiated Rate	$10,935.47
Rate for Payer: Anthem Medicaid	$7,420.50
Rate for Payer: Anthem Medicare Advantage/PPO	$7,811.05
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$10,935.47
Rate for Payer: CareSource Just4Me Medicare	$10,544.92
Rate for Payer: Humana KY Medicaid	$7,420.50
Rate for Payer: Humana Medicare Advantage	$7,811.05
Rate for Payer: Kentucky WC Medicaid	$7,494.70
Rate for Payer: Molina Healthcare Benefit Exchange	$9,373.26
Rate for Payer: Molina Healthcare Medicaid	$7,568.91

CONFIANZA PRO 12 PTCA GW 180CM

Facility

$1,833.00

Service Code	HCPCS C1769
Hospital Charge Code	27000056
Hospital Revenue Code	272
Min. Negotiated Rate	$238.29
Max. Negotiated Rate	$1,759.68
Rate for Payer: Aetna Commercial	$1,411.41
Rate for Payer: Anthem POS/PPO/Traditional	$1,429.74
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cigna Commercial	$1,521.39
Rate for Payer: First Health Commercial	$1,741.35
Rate for Payer: Humana Commercial	$1,558.05
Rate for Payer: Medical Mutual Of Ohio HMO	$1,503.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,352.75
Rate for Payer: Molina Healthcare Benefit Exchange	$549.90
Rate for Payer: Ohio Health Choice Commercial	$1,613.04
Rate for Payer: Ohio Health Group HMO	$1,374.75
Rate for Payer: Ohio Health Group PPO Differential	$366.60
Rate for Payer: Ohio Health Group PPO No Differential	$238.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$568.23
Rate for Payer: PHCS Commercial	$1,759.68
Rate for Payer: United Healthcare All Payer	$1,613.04

CONFIANZA PRO 12 PTCA GW 180CM

Facility

$1,833.00

Service Code	HCPCS C1769
Hospital Charge Code	27000056
Hospital Revenue Code	272
Min. Negotiated Rate	$238.29
Max. Negotiated Rate	$1,759.68
Rate for Payer: Aetna Commercial	$1,411.41
Rate for Payer: Anthem Medicaid	$630.37
Rate for Payer: Anthem POS/PPO/Traditional	$1,429.74
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cigna Commercial	$1,521.39
Rate for Payer: First Health Commercial	$1,741.35
Rate for Payer: Humana Commercial	$1,558.05
Rate for Payer: Humana KY Medicaid	$630.37
Rate for Payer: Kentucky WC Medicaid	$636.78
Rate for Payer: Medical Mutual Of Ohio HMO	$1,503.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,352.75
Rate for Payer: Molina Healthcare Benefit Exchange	$549.90
Rate for Payer: Molina Healthcare Medicaid	$643.02
Rate for Payer: Ohio Health Choice Commercial	$1,613.04
Rate for Payer: Ohio Health Group HMO	$1,374.75
Rate for Payer: Ohio Health Group PPO Differential	$366.60
Rate for Payer: Ohio Health Group PPO No Differential	$238.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$568.23
Rate for Payer: PHCS Commercial	$1,759.68
Rate for Payer: United Healthcare All Payer	$1,613.04

CONFIANZA PRO 12 PTCA GW 300CM

Facility

$1,770.00

Service Code	HCPCS C1769
Hospital Charge Code	27000056
Hospital Revenue Code	272
Min. Negotiated Rate	$230.10
Max. Negotiated Rate	$1,699.20
Rate for Payer: Aetna Commercial	$1,362.90
Rate for Payer: Anthem Medicaid	$608.70
Rate for Payer: Anthem POS/PPO/Traditional	$1,380.60
Rate for Payer: Cash Price	$885.00
Rate for Payer: Cigna Commercial	$1,469.10
Rate for Payer: First Health Commercial	$1,681.50
Rate for Payer: Humana Commercial	$1,504.50
Rate for Payer: Humana KY Medicaid	$608.70
Rate for Payer: Kentucky WC Medicaid	$614.90
Rate for Payer: Medical Mutual Of Ohio HMO	$1,451.40
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,306.26
Rate for Payer: Molina Healthcare Benefit Exchange	$531.00
Rate for Payer: Molina Healthcare Medicaid	$620.92
Rate for Payer: Ohio Health Choice Commercial	$1,557.60
Rate for Payer: Ohio Health Group HMO	$1,327.50
Rate for Payer: Ohio Health Group PPO Differential	$354.00
Rate for Payer: Ohio Health Group PPO No Differential	$230.10
Rate for Payer: Ohio Health Group PPO SOMC Employees	$548.70
Rate for Payer: PHCS Commercial	$1,699.20
Rate for Payer: United Healthcare All Payer	$1,557.60

CONFIANZA PRO 12 PTCA GW 300CM

Facility

$1,770.00

Service Code	HCPCS C1769
Hospital Charge Code	27000056
Hospital Revenue Code	272
Min. Negotiated Rate	$230.10
Max. Negotiated Rate	$1,699.20
Rate for Payer: Aetna Commercial	$1,362.90
Rate for Payer: Anthem POS/PPO/Traditional	$1,380.60
Rate for Payer: Cash Price	$885.00
Rate for Payer: Cigna Commercial	$1,469.10
Rate for Payer: First Health Commercial	$1,681.50
Rate for Payer: Humana Commercial	$1,504.50
Rate for Payer: Medical Mutual Of Ohio HMO	$1,451.40
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,306.26
Rate for Payer: Molina Healthcare Benefit Exchange	$531.00
Rate for Payer: Ohio Health Choice Commercial	$1,557.60
Rate for Payer: Ohio Health Group HMO	$1,327.50
Rate for Payer: Ohio Health Group PPO Differential	$354.00
Rate for Payer: Ohio Health Group PPO No Differential	$230.10
Rate for Payer: Ohio Health Group PPO SOMC Employees	$548.70
Rate for Payer: PHCS Commercial	$1,699.20
Rate for Payer: United Healthcare All Payer	$1,557.60

CONFIANZA PTCA GW 300CM

Facility

$1,787.50

Service Code	HCPCS C1769
Hospital Charge Code	27000056
Hospital Revenue Code	272
Min. Negotiated Rate	$232.38
Max. Negotiated Rate	$1,716.00
Rate for Payer: Aetna Commercial	$1,376.38
Rate for Payer: Anthem Medicaid	$614.72
Rate for Payer: Anthem POS/PPO/Traditional	$1,394.25
Rate for Payer: Cash Price	$893.75
Rate for Payer: Cigna Commercial	$1,483.62
Rate for Payer: First Health Commercial	$1,698.12
Rate for Payer: Humana Commercial	$1,519.38
Rate for Payer: Humana KY Medicaid	$614.72
Rate for Payer: Kentucky WC Medicaid	$620.98
Rate for Payer: Medical Mutual Of Ohio HMO	$1,465.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,319.18
Rate for Payer: Molina Healthcare Benefit Exchange	$536.25
Rate for Payer: Molina Healthcare Medicaid	$627.06
Rate for Payer: Ohio Health Choice Commercial	$1,573.00
Rate for Payer: Ohio Health Group HMO	$1,340.62
Rate for Payer: Ohio Health Group PPO Differential	$357.50
Rate for Payer: Ohio Health Group PPO No Differential	$232.38
Rate for Payer: Ohio Health Group PPO SOMC Employees	$554.12
Rate for Payer: PHCS Commercial	$1,716.00
Rate for Payer: United Healthcare All Payer	$1,573.00

CONFIANZA PTCA GW 300CM

Facility

$1,787.50

Service Code	HCPCS C1769
Hospital Charge Code	27000056
Hospital Revenue Code	272
Min. Negotiated Rate	$232.38
Max. Negotiated Rate	$1,716.00
Rate for Payer: Aetna Commercial	$1,376.38
Rate for Payer: Anthem POS/PPO/Traditional	$1,394.25
Rate for Payer: Cash Price	$893.75
Rate for Payer: Cigna Commercial	$1,483.62
Rate for Payer: First Health Commercial	$1,698.12
Rate for Payer: Humana Commercial	$1,519.38
Rate for Payer: Medical Mutual Of Ohio HMO	$1,465.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,319.18
Rate for Payer: Molina Healthcare Benefit Exchange	$536.25
Rate for Payer: Ohio Health Choice Commercial	$1,573.00
Rate for Payer: Ohio Health Group HMO	$1,340.62
Rate for Payer: Ohio Health Group PPO Differential	$357.50
Rate for Payer: Ohio Health Group PPO No Differential	$232.38
Rate for Payer: Ohio Health Group PPO SOMC Employees	$554.12
Rate for Payer: PHCS Commercial	$1,716.00
Rate for Payer: United Healthcare All Payer	$1,573.00

CONIZATION OF CERVIX

Facility

$600.00

Service Code	HCPCS 57522
Hospital Charge Code	76102204
Hospital Revenue Code	761
Min. Negotiated Rate	$78.00
Max. Negotiated Rate	$3,784.94
Rate for Payer: Aetna Commercial	$462.00
Rate for Payer: Anthem Medicaid	$206.34
Rate for Payer: Anthem Medicare Advantage/PPO	$2,703.53
Rate for Payer: Anthem POS/PPO/Traditional	$468.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,784.94
Rate for Payer: CareSource Just4Me Medicare	$3,649.77
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cigna Commercial	$498.00
Rate for Payer: First Health Commercial	$570.00
Rate for Payer: Humana Commercial	$510.00
Rate for Payer: Humana KY Medicaid	$206.34
Rate for Payer: Humana Medicare Advantage	$2,703.53
Rate for Payer: Kentucky WC Medicaid	$208.44
Rate for Payer: Medical Mutual Of Ohio HMO	$492.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$442.80
Rate for Payer: Molina Healthcare Benefit Exchange	$3,244.24
Rate for Payer: Molina Healthcare Medicaid	$210.48
Rate for Payer: Ohio Health Choice Commercial	$528.00
Rate for Payer: Ohio Health Group HMO	$450.00
Rate for Payer: Ohio Health Group PPO Differential	$120.00
Rate for Payer: Ohio Health Group PPO No Differential	$78.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$186.00
Rate for Payer: PHCS Commercial	$576.00
Rate for Payer: United Healthcare All Payer	$528.00

CONIZATION OF CERVIX

Facility

$600.00

Service Code	HCPCS 57522
Hospital Charge Code	76102204
Hospital Revenue Code	761
Min. Negotiated Rate	$78.00
Max. Negotiated Rate	$576.00
Rate for Payer: Aetna Commercial	$462.00
Rate for Payer: Anthem POS/PPO/Traditional	$468.00
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cigna Commercial	$498.00
Rate for Payer: First Health Commercial	$570.00
Rate for Payer: Humana Commercial	$510.00
Rate for Payer: Medical Mutual Of Ohio HMO	$492.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$442.80
Rate for Payer: Molina Healthcare Benefit Exchange	$180.00
Rate for Payer: Ohio Health Choice Commercial	$528.00
Rate for Payer: Ohio Health Group HMO	$450.00
Rate for Payer: Ohio Health Group PPO Differential	$120.00
Rate for Payer: Ohio Health Group PPO No Differential	$78.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$186.00
Rate for Payer: PHCS Commercial	$576.00
Rate for Payer: United Healthcare All Payer	$528.00

CONIZATION OF CERVIX

Professional

Both

$600.00

Service Code	HCPCS 57522
Hospital Charge Code	76102204
Hospital Revenue Code	761
Min. Negotiated Rate	$181.31
Max. Negotiated Rate	$600.00
Rate for Payer: Aetna Commercial	$363.40
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$181.31
Rate for Payer: Anthem Medicaid	$205.93
Rate for Payer: Buckeye Medicare Advantage	$600.00
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cigna Commercial	$357.14
Rate for Payer: Healthspan PPO	$380.37
Rate for Payer: Humana Medicaid	$205.93
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$314.42
Rate for Payer: Molina Healthcare CHIP/Medicaid	$210.05
Rate for Payer: Molina Healthcare Passport	$205.93
Rate for Payer: Multiplan PHCS	$360.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$420.00
Rate for Payer: UHCCP Medicaid	$190.38
Rate for Payer: Wellcare CHIP/Medicaid	$207.99

Know your out-of-pocket cost for care.

All Charges